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Yes. Your spouse and children may enroll in TRICARE Prime as long as it is offered in their area. An enrollment application (available in pdf format
here) must be submitted in order to participate in the program. You may also download the form on www.triwest.com by clicking the "Find A Form" tab on the left side of the screen.
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Yes. Reserve component members separated from active duty and mobilized in support of a contingency operation for an active duty period of more than 30 days are eligible for the Transitional Assistance Management Program (TAMP). Your coverage will begin after your separation date and end 180 days later. You may verify eligibility for yourself and your family members by visiting or contacting the nearest uniformed services ID card facility or contacting the Defense Manpower Data Center Support Office toll free at (800) 538-9552. To locate the nearest ID card facility, visit
www.dmdc.osd.mil/rsl/.
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Yes. Reserve component members separated from active duty and mobilized in support of a contingency operation for an active duty period of more than 30 days are eligible for the Transitional Assistance Management Program (TAMP). Your coverage will begin after your separation date and end 180 days later. You may verify eligibility for yourself and your family members by visiting or contacting the nearest uniformed services ID card facility or contacting the Defense Manpower Data Center Support Office toll free at (800) 538-9552. To locate the nearest ID card facility, visit
http://www.dmdc.osd.mil/rsl/.
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No. You can get your newborn enrolled in DEERS as long as you have a certificate of live birth. Newborns are listed under the sponsor's Social Security number. You should contact your local Social Security Administration office to find out how to get a Social Security number and card for your newborn. You need to try to get your newborn entered into DEERS within 90 days of the newborn's birth date or as soon as you can depending on when you receive the Social Security card. Newborn rule - 60 days
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Not if you enroll when you are first eligible. The 45-day break in coverage does not count as a significant break in coverage under HIPAA. Under federal law, a significant break in coverage is a break in coverage of at least 63 consecutive days. Since you had over 12 months of creditable coveerage from your previous group plan without a significant break, you would not be subject to the preexisting condition exclusion period imposed by your new employer's plan if you enroll when you are first eligible.
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You may verify eligibility for yourself and your family members by visiting or contacting the nearest uniformed services ID card facility or contacting the Defense Manpower Data Center Support Office toll free at (800) 538-9552. Click
here to locate the nearest ID card facility.
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You have to remember that the goal with TRICARE Prime is to deliver care locally as often as possible through our network of providers (military and civilian). Sometimes, however, you may have to travel more than 100 miles to get care. You have an active role in the appointment process and so you will be in a good position to determine if this benefit applies. Here is how it works: You have to have a referral from your PCM. You need to make sure the referral is reviewed and the care is approved, or as we say, "authorized". For this information, call TriWest at 1-888-TRIWEST (874-9378). If when you make the appointment, you believe the location of this appointment requires you to travel more than 100 miles FROM YOUR PCM'S LOCATION/OFFICE you can contact a patient travel representative or a beneficiary counseling and assistance coordinator and they will help you determine if the travel entitlement applies.
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TPR is specific to geographic location, and eligibility is based on residence and/or work address. Permanently assigned active duty members and Reserve Component members on active duty for more than 30 consecutive days must live AND work more than 50 miles or approximately one hour’s drive time from the nearest MTF. To determine eligibility contact TriWest at 1-888-TRIWEST (874-9378) or visit the
TRICARE Prime Remote Web site.
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Upon separation/demobilization certain Reserve Component members and their eligible family members remain eligible for transitional TRICARE coverage under the Transitional Assistance Management Program (TAMP) . Care is available for a limited period of time and if Prime coverage is desired, the member and family must re-enroll in Prime upon the member's separation. Once the transitional period ends, certain Reserve Component member and their families can voluntarily purchase coverage under the Continued Healthcare Benefits Programs, which offers benefits similar to TRICARE. For more information about transition health care benefits, please call the toll free number of your regional contractor. For more information about the Continuing Health Care Benefits Program, please contact Humana Military Healthcare Services, Inc. at 1-800-444-5445, option 4 or visit the
CHCB Web site.
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Demonstration participants are limited to families of Reserve Component (National Guard and Reserve) called to active duty for more than 30 consecutive days in support of contingency operations that result from the terrorist attacks of September 11, 2001, under Executive Order 13223, 10 U.S.C. 12302, 10 U.S.C. 12301(d), or 32 U.S.C. 502(f). Such operations include, for example, Operation ENDURING FREEDOM and NOBLE EAGLE. You can check your eligibility status in DEERS by contacting the nearest Uniformed Services ID card facility (which you can locate
here) or call the Defense Manpower Data Center Support Office (DSO) at 1-800-538-9552. For more information regarding TRICARE benefits, contact TriWest at 1-888-TRIWEST (874-9378).
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Retired service members who have completed 20 years of service are entitled to TRICARE. Once you and your spouse are legally married, she will be also be entitled to TRICARE benefits. For your wife to use TRICARE, you must contact the nearest uniformed service ID card facility (which you can locate
here) to register her for military benefits and a uniformed services ID card. Call ahead for hours of operation and to learn what documents your wife will need to have with her. At the same time, check your own Defense Enrollment Eligibility Reporting System (DEERS) registration to ensure it’s up to date and reflects the change in your marital status. Call DEERS at 1-800-538-9552 or for the Deaf (TTY/TDD): 1-866-363-2883. Hours of Operation: Monday through Friday, 6 a.m. to 3:30 p.m. (Pacific time), except Federal holidays.
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Retired Reserve Component members, National Guard and Reservists, do not become eligible for space available care in a military treatment facility or TRICARE until they begin to receive retiree pay, typically at the age of 60. You can check your eligibility status in DEERS by contacting the nearest Uniformed Services ID card facility (which you can locate
here) or call the Defense Manpower Data Center Support Office (DSO) at 1-800-538-9552. For more information regarding TRICARE benefits, contact TriWest at 1-888-TRIWEST (874-9378).
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Yes. The Department of Defense implemented a Chiropractic Health Care Program for active duty personnel designated at 27 military treatment facilities (MTF).
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To participate in the TPRADFM you must “reside with” your sponsor in a TRICARE Prime Remote (TPR) ZIP code. “Reside with” means that eligible family members resided with the Service member on the effective date of the Reservist’s orders and remain living at the residence. The RC member is not required to be enrolled in TPR for his or her family to enroll in TPRADFM. To determine eligibility for TPRADFM, contact TriWest at 1-888-TRIWEST (874-9378) or verify eligibility based on your sponsor’s home and work ZIP codes
here.
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TRICARE beneficiaries under the age of 65 who become eligible for Medicare due to a disability can keep their TRICARE benefit, but only if they enroll in Medicare Part B. Dual-eligible (Medicare AND TRICARE) beneficiaries who are not enrolled in Medicare Part B lose their TRICARE eligibility, but may receive care at military treatment facilities if there is space available. Dual-eligible beneficiaries who are active duty family members remain eligible for TRICARE and are exempt from the requirement to enroll in Medicare Part B.
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TRICARE eligibility for the military sponsor begins on the effective date of his or her orders to active duty. Needed care will be provided by uniformed services military/medical treatment facilities and by authorized civilian health care providers. Families of activated reservists and National Guard members become eligible for health care benefits under TRICARE Standard or TRICARE Extra on the first day of the military sponsor's active duty, if his or her orders are for a period of more than 30 consecutive days of active duty, or if the orders are for an indefinite period. More information on eligibility and TRICARE benefits as a Reserve component family member can be found
here.
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To participate in TPRADFM, the beneficiary must live with his/her sponsor, the sponsor must live AND work more than 50 miles or approximately one hour's drive time from the nearest MTF. The sponsor must be eligible for TPR for the beneficiary to be eligible for TPRADFM. To determine eligibility for TPRADFM, the beneficiary should contact TriWest at 1-888-TRIWEST (847-9378) or check his/her eligibility based on the sponsor's home and work ZIP codes
here.
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All active duty Service members and their families, retirees and their family members, and their survivors in the seven uniformed services: Army, Navy, Air Force, Marines, Coast Guard, National Oceanic and Atmospheric Administration, and Public Health Service.
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There are some individuals that are not eligible for TRICARE:
- Individuals not registered in DEERS. There is a method to retroactively be registered in DEERS under certain situations. If this applies to you, visit the nearest uniformed services personnel office or ID Card-issuing facility. You can also call Defense Enrollment Eligibility Reporting System Beneficiary Center at 1-800-538-9552.
- Individuals who are Medicare eligible, qualify for Medicare Part A, but who are not enrolled in Medicare Part B.
- Individuals who are eligible for benefits under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
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No. Family members may be referred to non-chiropractic health care services in the military health system (physical therapy, family practice or orthopedics) or may seek chiropractic care in the local community at your own expense. Contact TriWest at 1-888-TRIWEST (874-3978) for more information.
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Yes. As a retiree under age 65, you and your eligible family members are eligible for TRICARE Prime as long as it is offered in your area. You must submit an enrollment application and pay an enrollment fee of $230 per individual or $460 per family. Contact your regional contractor to request an enrollment form or download a form
here.
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No. You can be TRICARE Standard, Extra or Prime and still be eligible for care in both systems. For more information, contact the VA facility in your area.
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Yes. If widows/widowers eligible for TRICARE remarry, they lose their eligibility for military health care unless their new spouse is a military retiree. In that instance, they would become eligible as their new spouse's family member.
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If you are enrolled in TPR and your dependents reside with you, they can participate in the TRICARE Prime Remote for Active Duty Family Members (TPRADFM) program. TPRADFM requires enrollment. You may download an enrollment form on www.triwest.com by clicking the "Find A Form" tab on the left side of the page. You may also call TriWest at 1-888-TRIWEST (874-9378) to request a form.
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To verify your TPR eligibility contact TriWest at 1-888-TRIWEST (874-9378) or
verify your eligibility online.
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Yes, as a dual-eligible beneficiary under 65, you may use TRICARE Extra. Contact TriWest at 1-888-TRIWEST (874-9378) for more information.
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Anyone other than active duty Service members are eligible to use TRICARE Extra and/or Standard. Active duty Service members are required to use TRICARE Prime. Call TriWest at 1-888-874-9378 for more information.
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Family members of active duty service members (ADSM) who died while on active duty and who were on active duty for at least 31 days before death, will continue to be treated as active duty family members for TRICARE cost-sharing purposes for 3 years after their active duty sponsor dies. After the three years is up, the family will be converted to Retiree status.
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Your family is not eligible for TRICARE benefits while you are inactivated. If you are mobilized and are on active duty for more than 30 consecutive days, your family's healthcare needs are covered under several TRICARE options, including TRICARE Prime, TRICARE Standard, TRICARE Extra, and TRICARE Prime Remote For Active Duty Family Members. For more information, please contact the toll free number for your regional contractor. More information can be found online at the TRICARE website
here.
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All TRICARE-eligible retired service family members from any of the seven uniformed services: Army, Navy, Air Force, Marines, Coast Guard, National Oceanic and Atmospheric Administration (NOAA) and Public Health Service (PHS), to include spouses, unmarried children, some former spouses, and survivors, are eligible to participate in the TRICARE Pharmacy Program. Also, some dependent parents and parents-in-law may be eligible to participate in the TRICARE Senior Pharmacy program if they meet certain requirements. It is imperative that information is kept current in the Department of Defense (DoD) Defense Enrollment Eligibility Reporting System (DEERS) since DEERS information determines whether you are eligible for the TRICARE Pharmacy Program. You can contact the regional support contractor (find the appropriate phone number at
www.tricare.osd.mil) or the DEERS Support Office Telephone Center at 1-800-538-9552 to validate your eligibility.
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If you have not registered your child in DEERS within one year (365 days) of his or her birth or adoption, DEERS will show "loss of eligibility" on day 366, and your child will no longer be able to receive TRICARE benefits until he or she is registered in DEERS. Registering your newborn or adopted child in DEERS is separate from enrolling your child in TRICARE Prime and is the first step to ensuring your child is eligible for TRICARE benefits.
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To get your newborn enrolled in DEERS you have to get a certificate of live birth from the hospital or birthing center where your baby was born. You also need a DD Form 1172 -- APPLICATION FOR UNIFORMED SERVICES IDENTIFICATION CARD DEERS ENROLLMENT -- signed by the newborn's sponsor. You need to take both of these forms to the nearest ID Card center or unit Personnel office to get your newborn enrolled in DEERS.
NOTE: If the sponsor's signature on the DD Form 1172 is not witnessed by DEERS, someone in the personnel office, or if the sponsor is unavailable to go to the DEERS office with the family, the sponsor's signature must be notarized on the copy provided in order to enroll a newborn in DEERS.
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Nothing. You don’t even have to renew your ID card. On October 1, 2003, DEERS changed their computer program so it automatically changes your DEERS record to your own SSN. To file a claim for care received before October 1, 2003, use your former spouse’s SSN. For care and claims submitted after October 1, 2003, use your own SSN.
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For beneficiaries currently enrolled in TRICARE Prime, the TAMP period begins upon the active duty sponsor's separation and that date will be the effective date for their enrollment. For beneficiaries not currently enrolled, the enrollment form must be submitted by the 20th of the month for your family to be enrolled the first day of the next month. If your enrollment form is submitted after the 20th of the month, your family will be enrolled the first day of the 2nd month that follows. Download an enrollment form from the "Find a Form" link on the left hand side of the page.
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Yes. As TAMP eligibles, you and your family may enroll in TRICARE Prime if you live near a military treatment facility or in a TRICARE Prime service area. You are required to submit a TRICARE Prime enrollment form and your enrollment is subject to the "20th of the month rule" if you were not enrolled in Prime immediately prior to TAMP eligibility. If you and your family were enrolled in Prime immediately prior to TAMP eligibility, there will be no break in Prime coverage. Download an enrollment form from the "Find a Form" section under "Quick Links" to the left.
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No, you do not need to complete an enrollment form. You may use TRICARE Extra on a case-by-case basis just by using network providers.
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Yes, TRICARE Plus enrollment status is reflected in DEERS.
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If your Sponsor is Active Duty and stationed in a remote location, you may be eligible to enroll in TRICARE Prime Remote (TPR). Enrollment in TPR requires submission of an enrollment form. Click
here to download an enrollment form, or click the "Find a Form" link on the left hand side of the page and locate the TRICARE Prime Enrollment Application & PCM Change Form.
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TRICARE Prime portability allows you to continue your TRICARE Prime coverage during a permanent or temporary move (of at least 30 days) to another TRICARE region where TRICARE Prime is available. Retirees and their family members using the TRICARE Prime portability benefit will stay enrolled in TRICARE Prime during their move without paying additional enrollment fees. When transferring from one region to another, do not disenroll from TRICARE Prime when leaving your current location. Once you get to your new location, you will transfer your enrollment by completing a new enrollment form and submitting it to your new regional contractor for coordination. Your new regional contractor is immediately responsible for your care upon receipt of a correctly completed enrollment application. Fees must be current in the losing Region before the Port will be processed.
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No, you do not need to complete and enrollment form. You may use TRICARE Standard on a case-by-case basis just by using network providers.
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To enroll in TRICARE Prime, an enrollment form must be submitted and the beneficiaries choosing to enroll must live within a Prime Service Area (PSA) or sign an Access Waiver. The completed form and fee (if applicable) must be received on or before the 20th of the current month for coverage to begin on the first day of the next month. If the form is received after the 20th, your coverage will become effective the first day of the second month. For detailed information, please visit your nearest TRICARE Service Center or contact TriWest Healthcare Alliance at 1-888-TRIWEST (1-888-874-9378).
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Active duty service members and their families do not pay enrollment fees for TRICARE benefits. For retirees, their families and survivors there is an annual enrollment fee of $230 for an individual or $460 for a family. The enrollment fee can be paid in full at the time of enrollment, in four quarterly installments or via monthly Allotment, Electronic Funds Transfer or Recurring Credit Card. To pay your TRICARE Prime enrollment fees online and set up automatic payments, visit TriWest's
ePay page.
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You should receive a bill approximately 30 days prior to the date in which your payment is due. Payments are due by the 1st of the month. If you do not receive your bill, please contact TriWest at 1-888-TRIWEST (874-9378). Failure to pay your quarterly installments could result in disenrollment and loss of eligibility to reenroll in TRICARE Prime for 12 months. The one year lockout does not apply if the disenrollment occurs on 9/30, which is the fiscal year end. You can also set up automatic quarterly payments using
ePay, TriWest's online electronic payment tool.
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Active duty family members and retirees and their family members and survivors who disenroll from TRICARE Prime will automatically be participating in TRICARE Standard. If you are disenrolled early for nonpayment of fees, or you request disenrollment without a move, you will not receive a refund (if applicable) and you may be ineligible to reenroll for a 12-month period.
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This is dependant upon your specific situation and needs. Typically, TRICARE will be the secondary payor to other comprehensive health insurance. Please contact TriWest at 1-888-TRIWEST (874-9378) for more information.
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Not all family members are required to enroll in TRICARE Prime. Depending on your specific situation and needs, it may be best, for example, for a spouse to be in TRICARE Prime, and a student son or daughter, to use Extra or Standard. Please contact TriWest at 1-888-TRIWEST (874-9378) for more information.
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Enrolling your newborn in TRICARE Prime is a personal decision that you have to make. TRICARE Prime offers a number of advantages such as priority access for care and reduced out-of-pocket expenses. TRICARE Prime coverage is provided for your newborn for the first 60 days of the newborn's life as long as they are registered in DEERS. After 60 days, your newborn is covered under the TRICARE Standard benefit. Please contact TriWest at 1-888-TRIWEST (874-9378) for more information.
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As a retired beneficiary who is eligible for Medicare Part A and Part B, you may enroll in TRICARE Prime and the enrollment fee is waived. You must maintain Medicare Part B to be eligible for TRICARE benefits. This rule does not apply to Active Duty Family Members (ADFM). ADFM may have Medicare Part A only and still be eligible for TRICARE benefits. You must follow the same rules that apply to all other TRICARE Prime enrollees. You must choose a primary care manager that is part of the TRICARE network. If you receive services covered by TRICARE but not by Medicare, you must meet the TRICARE Prime requirements (enrollment, referral, authorization) for TRICARE to pay the claim.
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You may enroll in TRICARE Prime at any time. The completed enrollment form must be received by TriWest on or before the 20th of the current month for coverage to begin on the first day of the next month. If the form is received after the 20th, your coverage will become effective the first day of the second month. Download an enrollment form from the "Find a Form" link on the left hand side of the page.
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Depending on the availability of the network providers in your area, you may be required to select a PCM. Each family member may choose a different PCM to fit his/her specific needs or the entire family may choose to use the same PCM. In locations where network providers are not available, you will be required to use the services of authorized TRICARE providers. Use the "Provider Directory" link on the left hand side of the page to find a list of PCMs.
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Yes. Enrollment in TRICARE Prime is for a 12-month period unless you move from the area or lose TRICARE eligibility.
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Yes. If you are disenrolled early for nonpayment of fees, or you request disenrollment without a move, you may not receive a refund (if applicable) and you may be ineligible to reenroll for a 12-month period. However, if you are a family member of an active E-1 to E-4 sponsor, you are not subject to the lockout provision. Also, the one year lockout does not apply if the disenrollment occurs on 9/30, which is the fiscal year end. Please contact TriWest at 1-888-TRIWEST (874-9378) for more information.
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No. The Enrollment plan transfer is not automatic. In order to update your enrollment to TRICARE Prime, you must submit an enrollment form and select a primary care manager to avoid expensive point-of-service charges and interruption of coverage. The Prime enrollment will be effective the day that TriWest receives your completed enrollment form. Download an Enrollment form by clicking
here, or from the Enrollment Forms area at the "Find A Form" link on the left side of the Beneficiary page at www.triwest.com.
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Active duty service members are covered under the TRICARE Prime program immediately. However, the enrollment process is not automatic. For administrative purposes it is required that you complete an enrollment form. Download the enrollment form from the "Find a Form" tab on the left side of the page.
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To participate in TRICARE Prime, you must submit an enrollment form and fee ($230 for individual or $460 for family). If you are transitioning from Active Duty Family Member to Retired Family Member status and are currently enrolled in Prime, the application must be received prior to your Sponsor's Active Duty Loss of Eligibility to keep continuous Prime coverage. If you are currently Standard, the form must be received on or before the 20th of the current month for coverage to begin the first day of the next month.
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Yes. An Active Duty Sponsor must be enrolled in TPR for the ADFM to be enrolled in TPR.
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As a retiree, you are allowed to transfer your enrollment twice during the same enrollment year. The caveat is that you must re-enroll to the original region. For example, you can transfer enrollment from region 1 to region 3, then transfer enrollment again back to region 1 (but you cannot transfer to a third region in one year). You will be covered for emergency care under TRICARE Prime from your original region while en route to the next region. Fees must be current in the losing Region for the Port to be processed.
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No. Pre-existing conditions will not disqualify you from enrolling in TRICARE Prime.
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Yes, but you need to enroll in your new TRICARE region first. Your enrollment cards will be issued after your application is processed. TriWest is the West Region contractor and you can download the application
here.
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To change from TPR to Prime, you must submit a new Prime Enrollment form. Download an enrollment form from the "Find a Form" link on the left hand side of the page.
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Yes. Beneficiaries eligible for Medicare on the basis of disability or end stage renal disease that are: (1) under age 65, and (2) enrolled in Medicare Part B, are eligible to enroll in Prime and have the enrollment fee waived. You will be covered by both Medicare and TRICARE. Medicare would be the primary payer and TRICARE secondary. When you reach age 65, you must receive your health care through Medicare and TRICARE for Life as you will no longer be eligible for Prime.
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Your sponsor is not required to be enrolled in TPR for you to enroll in TPRADFM. To determine eligibility for TPRADFM, contact TriWest at 1-888-TRIWEST (874-9378).
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Shortly after enrolling in TPR, you should receive a welcome letter in the mail that includes an enrollment card. This card has your personal information on it along with key phone numbers and other information about your TPR benefits. Take this card to your medical appointments and show it with your uniformed services ID card as proof of TPR enrollment. If you do not receive your TPR welcome letter and ID card within 2 weeks of submitting your enrollment form, contact TriWest at 1-888-TRIWEST (874-9378).
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No. Under TAMP, you (the sponsor) are not eligible to enroll or reenroll in TRICARE Prime Remote since you are no longer on active duty. You may however be covered under TRICARE Prime, TRICARE Extra, and TRICARE Standard. Contact TriWest at 1-888-TRIWEST (874-9378) for more information.
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No. If you and your family are enrolled in TRICARE Prime and you wish to continue your TRICARE Prime enrollment you must complete an enrollment form. This reenrollment form will ensure that TRICARE Prime coverage continues with no break in coverage. Download an enrollment form from the "Find a Form" link on the left hand side of the page.
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If you are on active duty you must be enrolled in TRICARE Prime. All other beneficiaries who decide not to enroll in TRICARE Prime will still be eligible for care in military treatment facilities on a space available basis and maintain TRICARE Standard eligibility. They may also participate in TRICARE Extra by choosing a provider in the TRICARE network or they may use their own private health care insurance.
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TRICARE Prime offers more cost-saving features compared to the other TRICARE options. It's highly recommended for beneficiaries who want guaranteed access to timely health care. Care is usually provided in a military treatment facility (MTF), but civilian clinics may be used in some cases. TRICARE Prime also focuses on preventive and wellness care, and there's no annual deductible. Consult TriWest at 1-888-874-9378 for more information.
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The TRICARE Prime Handbook is available online in the Member Services section. In the Members Services section are also pamphlets and brocheres for your reference. The TRICARE resources section has articles that compare the different TRICARE plans. You may also contact TriWest at 1-888-874-9378 to request printed materials.
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No. To use the MTF for routine, specialty care, and inpatient services, your civilian PCM must refer you to the MTF. You may however use a MTF for pharmacy, laboratory, radiology and other ancillary benefits you may require. Contact your PCM for more information.
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Yes. You may request a change in PCM at any time. Changes will be accommodated to the extent that other network providers are available or to a non-network provider if circumstances support that decision. For assistance in switching your PCM, please contact your regional contractor.
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TRICARE is the Department of Defense's health care program for members of the uniformed services and their families and survivors, and retired members and their families. TRICARE brings together the health care resources at Military Treatment Facilities (MTFs) and supplements them with networks of civilian health care professionals to provide quality care and better access to our beneficiaries.
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Here are a few great sources of information to get answers regarding TRICARE: Contact your TRICARE Service Center; contact the Beneficiary Counseling and Assistance Coordinator (BCAC) or the Health Benefit Advisor (HBA) at any military treatment facility; or contact TriWest. You may also visit the TRICARE website at
http://www.TRICARE.osd.mil.
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The Uniformed Services (Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, NOAA, and Reserve/Guard Components) are responsible for ensuring you are qualified for worldwide service. If there is a question about your continued ability to perform assigned duties or stay on active duty, the Service Point of Contact (SPOC) at MMSO will refer you to the nearest MTF with the specialty care required to make a qualified evaluation. If you have further questions, please contact their your SPOC at 1-888-647-6676
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In some areas, there may not be any network providers or Primary Care Managers (PCMs). You are then free to use any authorized TRICARE provider in the local area. TRICARE Authorized Providers are health care providers who meet licensing, accreditation or other standards for the health care community and are specifically listed as being authorized to see TRICARE beneficiaries. For help in locating a TRICARE authorized provider, use the
TriWest Provider Directory. In some cases, there may not be any providers in the local area, and beneficiaries may need to travel longer distances for medical care. If you are not sure, contact TriWest at 1-888-874-9378.
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Yes. TPR, though intended to increase your choices and improve access to care, it is not designed to keep you from using an MTF. If you prefer, you may go to an MTF even if it’s farther than 50 miles or approximately an hour’s drive away.
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The TPRADFM benefits are: Standardization - TPRADFM allows eligible family members who reside in remote stateside locations access to the same health care benefits as those who live in a military treatment facility (MTF) catchment area or Prime service area. A Local Provider - Under TPRADFM, eligible family members have access to a local provider for their primary health care needs. Preventive Care - The TPRADFM benefit offers a comprehensive array of preventive benefits, including immunizations and important screening tests. No out-of-pocket expenses - TPRADFM enrollees have no out-of-pocket expenses as long as they remain eligible, enroll in the program, and follow TRICARE program requirements about seeking care, coordinating referrals and authorizations, and using TRICARE authorized, participating providers. For more detailed benefit information, contact TriWest at 1-888-874-9378.
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The TPR benefits are: Standardization - TPR allows eligible Service members who reside in remote stateside locations access to the same health care benefits as those who live in a military treatment facility (MTF) catchment area or Prime service area. A Local Provider - Under TPR eligible Service members have access to a local provider for their primary health care needs. Preventive Care - The TPR benefit offers a comprehensive array of preventive benefits, including immunizations and important screening tests. No out-of-pocket expenses - TPR enrollees have no out-of-pocket expenses as long as they remain eligible, enroll in the program, and follow TRICARE program requirements about seeking care, coordinating referrals and authorizations, and using TRICARE authorized, participating providers. Active Duty Care Oversight - The Military Medical Support Office (MMSO) Service Point of Contact (SPOC) determines whether an ADSM's medical condition requires a military medical evaluation, or whether the Service member may obtain specialty care from a civilian provider. MMSO makes this determination based upon current Service-specific guidelines and clinical standards. Further information about services available from the MMSO can found at
http://www.tricare.mil/tma/MMSO/. For USPHS and NOAA, call the Beneficiary Medical Program at 1-800-368-2777 or visit
http://dcp.psc.gov/.
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The Point of Service is an option under TRICARE Prime that allows enrollees the freedom to seek and receive non-emergent health care services from any TRICARE authorized civilian provider, in or out of the network, without requesting a referral from their Primary Care Manager (PCM) or the Health Care Finder (HCF). When Prime enrollees choose to use the POS option, all requirements applicable to TRICARE Standard apply. Point-of-Service claims are subject to a deductible of $300 for an individual or $600 for a family plus 50% cost-shares for outpatient and inpatient claims, and excess charges up 15% over the allowed amount. The 50% cost-share continues to be applied even after the enrollment year catastrophic cap has been met.
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If your doctor is part of the TRICARE network of military and civilian providers, you may continue to use him/her. If your doctor is not on the list of network providers, you must choose a TRICARE network PCM, or switch to TRICARE Standard in order to stay with your preferred provider. Contact TriWest at 1-888-874-9378, or use the Provider Directory from the "Find a Provider" tab to determine if your provider is part of the TRICARE network.
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To find out if your military treatment facility participates in the RACHAP you must call the Military Treatment Facility (MTF) and ask if the program is being offered. A Web site listing RACHAPP-participating facilities can be found here.
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Yes. Once your enrollment form is processed and your eligibility has been validated, you will receive a welcome letter in the mail from TriWest and a TPRADFM enrollment card. When you have medical appointments, your TPRADFM card along with your uniformed services ID card must be presented as verification of TPRADFM enrollment. If you do not receive your TPRADFM card within a couple of weeks of submitting your enrollment form, contact your regional contractor.
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You must contact your PCM whenever you require non-emergency (urgent) care. Your PCM will either provide the needed care or refer you to a specialist.
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Yes. If you would like to change your PCM, contact TriWest at 1-888-874-9378 for assistance or full out sections I, IV, VI, and V of the TRICARE Prime Enrollment application and PCM change form and mail it in.
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If your Primary Care Manager (PCM) thinks that you need to see a specialist, your PCM must obtain a pre-authorization from the Health Care Finder (HCF) before you obtain the specialty care. The HCF will assist in (1) obtaining pre-authorization, and (2) choosing a network specialist. If you do not have a PCM, you or your provider must contact the HCF for authorization to see the specialist. For more information, please contact TriWest at 1-888-874-9378.
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If you seek non-emergency or specialty care from other sources without first contacting your PCM or Health Care Finder (HCF), you will be held financially responsible for those health care services. If you do this, you will be getting care under the Point-of-Service option, which has higher costs. Please contact TriWest at 1-888-874-9378 for more information.
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Yes. As long as you have a referral from your PCM and the specialist is part of the TRICARE Network you may see a civilian provider. Contact TriWest for more information.
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TRICARE Plus is a military treatment facility primary care enrollment program that is offered at selected military treatment facilities. All beneficiaries eligible for care in military treatment facilities (except those enrolled in TRICARE Prime, a civilian HMO, or Medicare HMO) can seek enrollment for primary care at military treatment facilities where enrollment capacity exists. Enrollment in TRICARE Plus does not affect TRICARE For Life benefits or other existing program benefits. For more information call the nearest Military Treatment Facility to learn more about the TRICARE Plus program.
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You may use a provider that does not participate in TRICARE. However, please note that when TRICARE Prime beneficiaries use out-of-network, non-participating providers, their claims may process as Point of Service, which incurs higher out-of-pocket costs.
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If your Primary Care Manager (PCM) thinks that you need to see a specialist, your PCM must obtain a pre-authorization from the Health Care Finder (HCF) before you obtain the specialty care. If you do not have a PCM, you or your provider must contact the HCF for pre-authorization to see the specialist. Your HCF will call or fax you, your provider, or your PCM promptly regarding all requests for specialty care authorization. The HCF will communicate with the Service Point of Contact (SPOC). The SPOC will review all requests for specialty care to determine if your health care requires a "Fitness for Duty" determination. For DoD and Coast Guard members, your SPOC can be contacted at the Military Medical Support Office (MMSO) at 1-888-MHS-MMSO (1-888-647-6676). Note: Coast Guard members may also call 1-800-9HBA-HBA (1-800-942-2422). For USPHS and NOAA members, call the Beneficiary
Medical Program SPOC at 1-800-368-2777 option 2. If the SPOC thinks that your condition may change your fitness for military duty or requires a medical board, you will be referred to the closest Military Treatment Facility (MTF) with the ability to provide the care and make a duty determination. If the SPOC thinks there is no impact on your fitness for duty, you can be referred to a civilian specialist for the care.
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In some areas, there may not be any network providers or Primary Care Managers (PCMs). You are then free to use any authorized TRICARE provider in the local area. TRICARE Authorized Providers are health care providers who meet licensing, accreditation or other standards for the health care community and are specifically listed as being authorized to see TRICARE beneficiaries. To locate an authorized provider, use the
TriWest Provider Directory. In some cases, there may not be any providers in the local area, and you may need to travel longer distances for medical care. If you are not sure, contact TriWest at 1-888-TRIWEST (874-9378) to check if there are TRICARE providers in your area.
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Yes. If there is more than one network provider in your area, you have the freedom to choose one that is convenient for you. If you are in an area with no network providers, you may use any TRICARE-authorized provider. To locate a TRICARE authorized provider, use the Provider Directory on www.triwest.com. In some cases, there may not be any providers in the local area, and beneficiaries may need to travel longer distances for medical care. If you are not sure, contact TriWest at 1-888-TRIWEST (874-9378) to check if there are TRICARE providers in your area.
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Yes. TPRADFM, though intended to increase your choices and improve access to care, it is not designed to keep you from using an MTF if you prefer.
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Yes. Active Duty personnel assigned to a military treatment facility (MTF) with a chiropractic clinic may be treated by a doctor of chiropractic for neuro-musculoskeletal conditions, subject to a referral by their primary care manager (PCM) and availability of appointments.
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You may view the TRICARE Prime Handbook in the Member Services section of
www.triwest.com. You may also visit the TRICARE Web site
here. Call TriWest at 1-888-TRIWEST (874-9378) for more information.
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By law, care given at an MTF for TRICARE Prime enrollees is prioritized in this order:
- Active Duty personnel
- Active Duty family members enrolled in TRICARE Prime
- Retirees, survivors, and their family members enrolled in TRICARE Prime
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An advantage of being enrolled in TRICARE Prime is the policy directed access standards for TRICARE appointments. They are as follows: Urgent care 24 hours; Routine appointment 7 days; Routine specialty care 28 days; and Wellness, health promotion 28 days.
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Yes. When you enroll in TRICARE Prime, you must select a PCM. Since your PCM keeps track of your medical records and knows your medical history, he or she can recognize your health care needs. Each family member may choose a different PCM to fit his/her specific needs or the entire family may choose to use the same PCM. Use the Provider Directory from the "Find a Provider" tab on
www.triwest.com to choose your PCM or call TriWest at 1-888-TRIWEST (874-9378) for a list of PCMs to choose from. If you do not choose a PCM, TriWest will assign one to you.
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The TDEFIC is a single, nationwide contract for claims processing, customer service and administrative services for individuals who are dually eligible for TRICARE and Medicare, regardless of whether they are over or under age 65. This contract has been awarded to Wisconsin Physicians Service (WPS) of Madison, Wisconsin. Over a five-month period, beginning June 1, 2004, TDEFIC will complete phase-in across the country, by region, replacing the current practice of managed care support contractors providing these services.
Transition will begin with Region 11 on June 1, 2004.
Regions 9, 10 and 12 will transition July 1, 2004.
Region 6 will transition November 1, 2004.
As part of its new responsibilities, WPS will notify beneficiaries of process changes, the appropriate address for filing paper claims and phone numbers for reaching customer service representatives.
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Yes, your dual-eligibility status can be reflected in DEERS. However, for DEERS to show your dual-eligibility status, you must take your Medicare card, showing your Medicare Parts A and B effective dates, to the nearest ID card facility (you can locate the nearest one online
here), or call the Defense Manpower Data Center Support Office (DSO) at 1-800-538-9552 for more information.
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No, there is no limit. However, TRICARE must deem ALL services "medically necessary" and must be referred by your PCM if enrolled in TRICARE Prime.
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Yes. However, RC members ordered to active duty for 31 consecutive days or more and their family members are eligible for the Continued Healthcare Benefits Program similar to TRICARE Standard upon release from active duty or when no longer eligible for healthcare under the Military Healthcare System (MHS). RC members ordered to active duty in support of a contingency operation for 31 days or more are eligible for Transitional Healthcare under TRICARE upon release from active duty. Continued Healthcare Benefits Program: RC members, who served on active duty for 31 days or more and are not eligible for the transitional healthcare benefit, may enroll in the Continued Healthcare Benefits Program (CHCBP) upon release from active duty. This program provides healthcare benefits similar to TRICARE Standard for up to 18 months to RC members and their family when released from active duty or those who are no longer eligible for healthcare under the Military Medical Healthcare System. Eligible members must enroll in the CHCBP within 60 days after release from active duty or loss of eligibility for military healthcare. The member is responsible for quarterly premiums from $933 per individual to $1966 per family. For more information about CHCBP, call toll free: 1-800-444-5445, visit
www.humana-military.com, or write to Humana Military Healthcare Services Inc., Attn: CHCBP, P.O. Box 740072, Louisville, KY 40201. Transitional Healthcare Benefits: RC members ordered to active duty for 31 days or more in support of a contingency operation are entitled to transitional healthcare benefits upon release from active duty. RC members separated with less than 6 years of cumulative active federal service (indicated on the member’s DD214) are eligible for 60 days of transitional healthcare. Those members with 6 or more years of cumulative active federal service are eligible for 120 days of transitional healthcare. Family members are also eligible for transitional healthcare for either 60 days or 120 days depending on the total cumulative years of active federal service of the sponsor/service member. Upon termination of the transitional healthcare benefit period, the member may enroll himself/herself and eligible family members in the CHCBP described above. For more information about transitional health care benefits, contact TriWest at 1-888-874-9378.
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Non-participating providers may require payment up front, before, or at the time of health care delivery. If so, you (ADSM) have a true out-of-pocket cost.
If the care is a covered benefit and was authorized, you will be reimbursed for actual costs once a claim is filed.
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You do not need to enroll or pay an annual fee for TRICARE Standard or Extra, however you do need to satisfy an annual deductible for outpatient care before government cost sharing starts. When you use network providers you exercise the TRICARE Extra option. Using any TRICARE authorized provider not in the network is the TRICARE Standard option. You may choose these options on a visit by visit basis. Under TRICARE Standard you will pay cost-shares five percent higher than under TRICARE Extra. When you use TRICARE Standard, you generally will have to file paper claim forms.
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If you are eligible for TRICARE Prime, it would be the most cost-efficient option for you. If there is not an MTF in your area, contact your regional contractor to inquire about civilian TRICARE Prime providers. If there is not a TRICARE Prime provider in your area, you can still reduce your out-of-pocket expenses by using a civilian network provider with TRICARE Extra. If such a provider is not available in your area, you will have the option of using TRICARE Standard. The TRICARE Service Center (TSC) in your region has lists of both TRICARE Prime and TRICARE Extra providers.
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No. TRICARE Plus is not transferable to other MTFs. You will be considered for care at other MTFs on a "space-available" basis. For more information call the nearest Military Treatment Facility to learn more about the TRICARE Plus program.
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You can ask the provider's office directly or contact your regional contractor since they may have information on your particular provider. Remember, as a dual-eligible, you can use any Medicare-authorized provider for your health care needs and TRICARE will pay for appropriate, covered services.
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TRICARE Prime Remote (TPR) is a program that provides active duty service members in the United States with a specialized version of TRICARE Prime while they are assigned to duty stations in areas not served by the traditional military healthcare system. You must verify your eligibility for the TPR program. Eligibility can be verified through the
TRICARE Web site or by calling TriWest at 1-888-TRIWEST (874-9378). If you are eligible, enroll immediately. This will provide you with primary care access in your area without the need for pre-authorization. Specialty care will need to be coordinated with your regional Health Care Finder (HCF) for pre-approval by the Military Medical Support Office (MMSO). Active duty service members pay nothing for approved health care delivered by authorized civilian providers. For primary care, no authorization is required when you obtain care from your PCM. For specialty care, your PCM or doctor must make the referral and you must have an authorization from the HCF. This includes hospitalizations, ambulatory surgery, and other visits to specialists.
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No. Family members of an active duty service member are not required to purchase Medicare Part B to participate in the TRICARE benefit However, when your sponsor retirees you will be required to purchase Medicare Part B in order to use the TRICARE benefit.
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You may use Extra or Standard on a visit by visit basis. To use TRICARE Extra you must use a TRICARE network provider. The advantage of utilizing TRICARE Extra is lower cost shares. Consult TriWest at 1-888-874-9378 for more information.
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There aren't any out-of-pocket costs for covered services. The MTF can bill you for non-covered services if you have other health insurance. You will be seen on a space-available-basis only. Consult the MTF in your area for more information.
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You are free to choose any doctor or healthcare provider who is TRICARE authorized. TRICARE authorized providers are specifically listed as being authorized to provide benefits under TRICARE. Regional TRICARE contractors must certify a provider's authorized status before making payment. Use the
TriWest Provider Directory to find an authorized provider, or call TriWest at 1-888-TRIWEST (874-9378).
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TRICARE has no pre-existing condition limitations.
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No, the point-of-service option does not apply to TRICARE Extra.
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Yes. No matter what time zone you live in stateside, you will be able to speak real time with the TRICARE Dual-Eligible Fiscal Intermediary Contract (TDEFIC) contractor service staff during normal business hours for your time zone. Live operator services typically end at 5 p.m. The TDEFIC contractor will provide automated services around the clock.
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TRICARE Prime beneficiaries classified as Active Duty Service Members (ADSMs) or Active Duty Family Members (ADFMs) have no copayments for TRICARE covered services. Retirees, their family members, and survivors, have the following copay structure: Out patient visits with a civilian provider $12.00; Inpatient services with a civilian provider $11.00 per day ($25.00 minimum); Emergency care with a civilian provider $30.00; Mental health visits with a civilian provider $25.00, $17 (group visit); and Mental health inpatient services with a civilian provider $11/day ($25 minimum) Charge per admission.
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If the NMA is active duty or a Department of Defense civilian employee AND is authorized by the MTF or Lead Agent to accompany the Prime-enrolled patient, the NMA is paid back up to the government TDY allowances (per diem and mileage), not actual expenses. These individuals have to file a DD Form 1351-2 along with original orders and receipts to receive reimbursement. If the NMA is a civilian not employed by the Department of Defense AND is approved by the MTF or Lead Agent, the NMA is authorized reimbursement of actual travel costs, not to exceed the government rate for the area to which they are traveling (JFTR U7960-C and U7960-D). These individuals will need to file an SF 1164 and attach original orders and receipts. It is important that you understand that what the patient and NMA received back in payment for their actual expenses are capped at the government rate for transportation, lodging, per diem, etc. For more information please contact the MTF Patient Travel Representative, or the Beneficiary Counseling and Assistance Coordinator if you are assigned to a PCM at an MTF. If you are assigned to a civilian network PCM outside the MTF, you need to contact the Patient Travel Representative or Beneficiary Counseling and Assistance Coordinator at the Lead Agent's office in the TRICARE region where you are enrolled.
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No, there is no enrollment fee.
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No. If you choose to receive care as a veteran and you have a copayment, you are responsible for the copayment. For more information, contact the VA facility in your area.
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Yes. TriWest currently offers three options for monthly payments: You may choose to pay by Electronic Funds Transfer (EFT) from a specified checking or savings account OR by a Recurring Credit/Debit Card payment with a Visa or MasterCard logo. If you choose to pay by this method, print the EFT authorization form and follow directions to complete. Registered members of www.triwest.com may also set up EFT payments online. If your retirement is paid through DFAS, the Public Health Service, or the Coast Guard, you can authorize TriWest to establish a monthly allotment from your retirement pay. If you choose to pay by this method, print the allotment authorization form and follow directions to complete.
Payment is also available online. Beneficiaries not registered at www.triwest.com can make a one-time payment here. Beneficiaries who register can log in to their account and make their payment via the fee payment page.
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TRICARE deductibles and copayments do increase periodically, but are not age-based payments.
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Yes, the catastrophic cap for TRICARE is $3,000 per year for retirees and their families and $1,000 per year for active duty and their families. The amount is inclusive of pharmacy benefits and any other services provided under TRICARE.
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There are no cost-shares for Active Duty Service members participating in the TRICARE Prime Remote (TPR) program. In some cases, non-participating providers may require payment up front, before, or at the time of health care delivery. If so, you will be reimbursed for actual costs once a claim is filed.
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First, you should have travel orders issued before you go to your specialty appointment. Upon your return you will need to complete the correct travel order form (Standard Form 1164) and submit it with your original receipts. You need to submit it to the address given to you by the Patient Travel Representative. Always make and keep copies for your own records. If you have questions regarding filing for reimbursement, please contact the patient travel representative who issued your travel orders.
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That depends on how long it will take for the Defense Finance Accounting Service to review your paperwork, determine the reimbursement, and get the check back to you.
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There is no premium or enrollment fee associated with the TPR program.
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There are no deductibles or copays for medical or pharmacy benefits for ADSMs enrolled in TPR.
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If you choose to use a TRICARE network provider, he/she will bill TRICARE for you. Otherwise you may need to pay for expenses up front and file a claim DD 2642 (available from the "Find a Form" tab) for reimbursement.
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Yes, a beneficiary must satisfy an annual deductible for care. Active duty family members pay a deductible of $150/individual or $300/family for E-5 & above; $50/$100 for E-4 & below. Retirees, their family members, and others pay a deductible of $150/individual or $300/family. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for details.
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In general, after you meet your deductible, the cost-share for care under TRICARE Standard will be 20% of the provider's fee. Call TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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In general, after you meet your deductible, the cost-share for care under TRICARE Standard will be 25% of the provider's fee. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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No. The catastrophic cap applies only to allowable charges for covered services. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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Yes, the maximum amount that your family will have to pay out-of-pocket per fiscal year (October 1-Septmeber 30), for TRICARE-covered medical services is different depending on the sponsor's status. There is an annual catastrophic cap under TRICARE Standard of $3,000.00 for retirees/retiree family members and $1,000.00 for active duty family members.
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There are no out-of-pocket expenses as long as you remain TRICARE eligible and follow TPRADFM program requirements about seeking care, coordinating referrals and authorizations, and using TRICARE authorized, participating providers. Call TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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Yes. Non-participating providers may require payment up front, before, or at the time of health care delivery. If so, you will have a true out-of-pocket cost. If the care is a covered benefit and was authorized you will be reimbursed up to 15 percent above the TRICARE reimbursement rates once a claim is filed. If the care was not-authorized, the you may be responsible for Point-of-Service charges. Contact TriWest, your regional contractor, at 1-888-TRIWEST (1-888-874-9378) for more information.
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Yes. You will receive a bill approximately 30 days prior to the date in which your payment is due. Payments are due by the 1st of the month. If you do not receive your bill, please call TriWest at 1-888-TRIWEST (1-888-874-9378).
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When you use a TRICARE network provider, the provider is responsible for filing the claim. After the claim has been submitted, you and your provider will receive an Explanation of Benefits (EOB) from the claims processor showing the services performed, how the claim was processed and paid, how much was paid to the provider, and how much you may owe.
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No, there is no annual fee to participate in TRICARE Extra.
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Yes, the maximum amount that your family will have to pay out-of-pocket per fiscal year (October 1-Septmeber 30), for TRICARE-covered medical services is different depending on the sponsor's status. There is an annual catastrophic cap under TRICARE Extra of $3,000.00 for retirees/retiree family members and $1,000.00 for active duty family members.
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In general, after you meet your deductible, the cost-share for care under TRICARE Extra will be 15% of the provider's fee.
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In general, after you meet your deductible, the cost-share for care under TRICARE Extra will be 20% of the provider's fee. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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Yes, there is an annual catastrophic cap under TRICARE Extra of $3,000.00.
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No, the catastrophic cap applies only to allowable charges for covered services. Consult your regional contractor for more information.
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There aren't any out-of-pocket costs for covered services. The MTF can bill you for non-covered services if you have other health insurance. You will be seen on a space-available-basis only. Consult the MTF in your area for more information.
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No, there is no annual fee to participate in TRICARE Standard.
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If you receive a notice from a collection agency or a negative credit report because of a medical or dental bill, you should call or visit the nearest Debt Collection Assistance Officer (DCAO). The DCAO cannot provide you with legal advice or fix your credit rating, but can help you through the debt collection process by providing you with documentation for your use with the collection or credit reporting agency in explaining the circumstances relating to the debt. The
DCAO Directory is located on the TRICARE Web site.
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Yes. If you are a registered member of Triwest.com and have uniformed services retirement pay you can make an online allotment request. Login to your account, go to the Online Billing area and select “Make A Payment”. Choose to initiate an allotment from the recurring payment types listed near the bottom.
You will be required to make a 3-month advance payment by credit card to make sure your account remains current during the request period.
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TRICARE Standard and Extra cover a very limited number of preventive services. You are responsible for the deductible and copayments associated with those services. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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Some VA Medical Facilities do have primary care managers that accept TRICARE beneficiaries. You may choose to use that primary care manager under your TRICARE benefits if you are not enrolled for primary care with the Veterans Affairs health care system. For more information, contact the VA facility in your area.
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If you need emergency care, go to the nearest military or civilian emergency room (or urgent care center) or call 911. You do not need to call your provider before receiving emergency medical care. However, you must contact your Primary Care Manager if one is assigned to you, or TriWest at 1-888-TRIWEST (1-888-874-9378) as soon as possible (within 24 hours) after getting emergency treatment or being admitted to a hospital. They can help with transferring you to a military hospital if necessary. They can also make sure that your medical bills are sent to the proper place for payment.
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Mental health and substance abuse treatments are covered under TRICARE Prime. If your provider of care believes you need more than five psychotherapy sessions a week in the hospital, or more than two psychotherapy sessions a week as an outpatient, TriWest must review the medical necessity for the care. If you need more than eight outpatient psychotherapy sessions in a fiscal year, approval is required. You must get approval for additional sessions from TriWest. Inpatient care which needs preauthorization is limited to a certain number of days per year unless TRICARE grants a waiver. Active Duty Family Members have no co-payments. Retirees and their families pay $25 per outpatient visit and $40 per day for an inpatient visit.
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If you need non-urgent or non-emergency care you are covered under TRICARE Prime as long as you obtain prior authorization from a Health Care Finder or your primary care manager (PCM). For non-emergent care call TriWest at 1-888-TRIWEST (1-888-874-9378); they will assist you in finding the closest and most appropriate source of care. If you see a civilian provider without authorization for a non-emergency problem, you are covered for medically necessary care under the point-of-service (POS) option. The POS option only pays 50 percent of the allowable charges for covered care and you are held accountable for the other 50 percent of the cost, after the appropriate deductible is paid. If emergency care is needed, please go to the closest emergency room, or call 911. If you receive emergency medical care and are hospitalized as a result, you or someone must notify your PCM or TriWest within 24 hours of receiving care.
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You must contact your PCM whenever you require non-emergency care. The PCM will either provide the needed care or refer you to a specialist.
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Routine medical and dental care should be (1) taken care of before you travel, (2) delayed until you return and can see your Primary Care Manager (PCM) or provider, or (3) delayed until you arrive at your new assignment.
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If you need non-urgent or non-emergency care you are covered under TRICARE Prime as long as you get prior authorization from your Primary Care Manager. If you see a civilian provider without authorization for a non-emergency problem, you will be responsible for some of the costs incurred under the Point-of-Service option. That option pays 50 percent of the cost after a separate, somewhat higher deductible is met ($300 for single enrollment and $600 for family enrollment).
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TRICARE covers the cost of hospice care for terminally ill patients who are expected to live fewer than 6 months if the illness runs its normal course. No limits exist on custodial care and personal comfort items under hospice care rules, as with other types of care. TRICARE also pays the full cost of covered hospice care services, except for small cost-share amounts that may be collected by the hospice for such things as drugs and inpatient respite care. Check with TriWest for details.
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If you need emergency care, go to the nearest military or civilian emergency room (or urgent care center) or call 911. You do not need to call your provider before receiving emergency medical care. However, you must contact your Primary Care Manager (PCM) (if one is assigned to you), or TriWest as soon as possible (within 24 hours) after getting emergency treatment or being admitted to a hospital. They can help with transferring you to a military hospital if necessary. They can also make sure that your medical bills are sent to the proper place for payment.
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Yes. Physical exams required by a school in connection with the enrollment of the student in that school are covered for TRICARE-eligible dependents who are at least 5 years old and less than 12 years. This benefit does not include physical exams that may be required by the school to participate in school sports. Contact TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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No matter where you travel, your TRICARE benefits cover you in an emergency situation. If you experience an emergency while away from your service area, go to the nearest emergency facility. Within 24 hours, call your Primary Care Manager (PCM) to report the emergency. See your PCM for any routine care before you travel. Routine care will not be authorized while you are traveling; only emergency care will be authorized. Contact TriWest at 1-888-TRIWEST (1-888-874-9378) for information on how to submit a claim for reimbursement for TRICARE-covered services.
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Yes, eye examinations are authorized every 2 years as a clinical preventive service. Prime enrollees who are diabetic are allowed an annual comprehensive eye examination. Contact TriWest at 1-888-TRIWEST (1-888-874-9378) for more specific information. Retired Prime - one every two years, ADFM - one every year, at a network provider only. If you choose to go a non-network provider, the claim will not pay unless there is an authorization on file.
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You will be assigned a primary care provider at the MTF. Appointments will use the same access standards as TRICARE Prime (urgent care, 24 hours; routine care, 7 days). Specialty care will be provided at MTFs if and when available.
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Screening eye exams are not covered when using TRICARE Standard/Extra unless the exam is related to a covered medical condition, such as cataracts or an eye injury. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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If you are VA-eligible and enrolled in TRICARE Prime, you must have a referral to be seen in a specialty clinic at a VA facility. If you are a VA-eligible and TRICARE Standard/Extra beneficiary you do not need a referral, but you will need to contact the TRICARE Beneficiary Point-of-Contact at the VA facility to make an appointment. TRICARE Standard beneficiaries must still obtain prior authorization for certain services. For more information, contact the VA facility in your area.
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No. Generally TRICARE does not cover experimental procedures. However, there are exceptions under the National Cancer Institute-approved clinical trials. Consult TriWest at 1-888-TRIWEST (1-888-874-9378) for more information.
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Anyone covered by TRICARE should seek treatment at the nearest emergency department right away if care is needed to safeguard life, limb or eyesight. If you're a TRICARE Prime enrollee you must notify TriWest or your PCM within 24 hours of admittance so that care can be coordinated.
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TRICARE Reserve Select (TRS) is a premium-based TRICARE health plan available for purchase by qualified members of the Reserve Components (RCs) that offers health coverage for RC members and their eligible family members
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For the new TRICARE Reserve Select (TRS) program effective October 1, 2007 there are two options for the enrollment start date. For Continuation Coverage: A qualified member may purchase TRS coverage with an effective date immediately following the termination of coverage under another TRICARE program in which the member is the sponsor. The TRS request must be either received in the TSC or postmarked no later than 60 days after the termination of other TRICARE coverage. (TOM 4.1.1) For Continuously Open Enrollment: A qualified member may purchase TRS coverage throughout the year. If the request and premium payment is received in the TSC or postmarked by the last day of the month, the effective date of TRS coverage shall either be the first day of the next month or the first day of the second following month as indicated on the TRS request. Requests for the next month that are postmarked in that month will be processed with an effective date of the first day of the month following the postmark date. (TOM 4.1.3) Learn more about TRS
here.
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Members of the Selected Reserve (no service agreement is required) may purchase coverage if they are not eligible for, or already enrolled in, the Federal Employees Health Benefits (FEHB) program.
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It is similar to TRICARE Standard coverage and has annual deductibles and cost-shares associated with medical services and an annual catastrophic cap applied to those costs. Eligible RC members must also pay a monthly premium to participate in the TRS Program. These premiums are not applied towards the catastrophic cap.
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There is no period of coverage limit, as long as you maintain status as reservists, you maintain eligibility for TRICARE Reserve Select. Tiers and service agreement are gone.
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There is no period of coverage limit, as long as they maintain status as reservists, they maintain eligibility for TRICARE Reserve Select. Tiers and service agreement are gone.
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Eligible Reserve Component members will be able to purchase this coverage on a member-only or member-and-family basis. The member must be enrolled in TRS in order for the family members to enroll as well.
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If you have a change in your family status, and you want those members to have TRICARE Reserve Select (TRS) coverage effective the date the Qualifying Life Event (QLE) occurred (i.e., date of marriage, date of birth, etc.) a TRS request form (DD 2896-1) must be submitted within 60 days of the qualifying event (the members must show eligible in DEERS). If you submit the form 61 days or more from the date of QLE, the effective date of TRS coverage will either be the first day of the next month, or the first day of the second following month, whichever you indicate on the TRS request form. When changing from Member and Family to Member Only coverage, their end date will be effective the last day of the month in which the form is postmarked or received, unless the end reason is due to QLE (such as divorce).
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Yes.
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Yes, the RC member will be responsible for paying a monthly premium for TRS coverage in addition to an annual deductible and cost-shares similar to those of TRICARE Standard.
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For calendar year 2008, the monthly premium for member-only coverage is $81, and the monthly premium for member-and-family coverage is $253. These premiums can be adjusted annually each January 1st.
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Yes. Under TRICARE Reserve Select, you will not be eligible for TRICARE Prime, TRICARE Prime Remote or TRICARE Prime Remote for Active Duty Family Members. In addition, neither the TRICARE Reserve Family Member Demonstration Program nor the Program for Persons with Disabilities/Extended Health Care Option applies to the TRS Program.
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At the time of release from active duty, some Reserve Component (RC) members will qualify for either TRICARE Reserve Select (TRS) or Continued Health Care Benefits Program (CHCBP). If you enroll in TRS but are later disenrolled, then you or your covered family members may activate CHCBP coverage for whatever portion of the original 18-month eligibility is left. For instance, if an RC member is disenrolled from TRS because of discharge from the Selected Reserve (perhaps through a reduction in force or base closure) within 18 months of his/her release from active duty, he/she could choose to continue health care coverage under CHCBP for the rest of the 18 months at the applicable CHCBP premiums.
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TRICARE Reserve Select (TRS) members and their covered family members are eligible for direct care in a Military Treatment Facility, including MTF pharmacies with the same access priority as ADFMs not enrolled in TRICARE Prime, but only on a space-available basis.
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No.
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You can periodically check this Web site and the TRICARE Management Activity web site at
http://www.tricare.osd.mil.
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An HMO is a health plan to which a beneficary pays a fixed premium for an assortment of medical services, usually including primary and preventive care. The primary purpose of an HMO is to coordinate care so as to eliminate unnecessary care and costs. HMOs typically have copays rather than cost-shares.
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Managed Care is a concept under which an organization (like an HMO) delivers health care to enrolled members. It controls costs by closely supervising and reviewing the delivery of care.
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TRICARE will consider payment for all necessary medical or psychological services which have been generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness.
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Military Treatment Facilities (MTF) are hospitals, clinics, etc., that are typically located on base and provide medical or dental services to eligible beneficiaries.
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A network provider is a healthcare professional who has signed an agreement with TRICARE stating, among other things, to accept assignment of benefit or the TRICARE Maximum Allowable Charge as payment in full. Network providers must file the claim on the patient's behalf.
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Authorizations may be needed for certain procedures. Typically, network or contracted TRICARE providers require authorizations to provide specialty or inpatient care. Prime beneficiaries require authorizations for specialty care provided out of the Primary Care Manager's office. Psychological and substance abuse care typically require authorization. Contact TriWest at 1-888-TRIWEST to determine if authorization is needed.
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A TRICARE-authorized provider is one whose provider status can be authorized by TRICARE as a legitimate provider of care, meeting specific educational, licensing, and other requirements. Authorized providers are not necessarily network providers. TRICARE will share costs for TRICARE-authorized procedures or services if a beneficiary sees a providers of this type, after the provider has become TRICARE-certified. A TRICARE-certified provider is TRICARE-authorized provider who has been certified by TriWest to provide services to TRICARE beneficiaries.
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Any person eligible for TRICARE benefits who is receiving care; the patient.
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A Beneficiary Counseling and Assistance Coordinator (BCAC) is a military or government employee, usually located at a Military Treatment Facility (MTF), who can address healthcare issues and concerns. Formerly known as a Health Benefits Advisor (HBA).
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The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1 - September 30). Point of service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.
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CHAMPUS is the former name of the military healthcare program that is now TRICARE.
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A claims processor is the TRICARE designated contractor who processes medical claims for care received within a particular state or region. Customer Service areas are available to answer your questions regarding claim status.
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The fixed amount a TRICARE Prime program option enrollee will pay for care in the civilian provider network. Active duty family members enrolled in a TRICARE Prime program option are not required to make copayments.
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The percentage of the allowable charges a beneficiary will pay under TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select. The cost-share depends on the sponsor's status (active duty or retired).
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The annual amount a TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select beneficiary must pay for covered outpatient benefits before TRICARE begins to share costs. TRICARE Prime beneficiaries do not have an annual deductible, unless they are utilizing their point of service option.
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The Defense Enrollment Eligibility Reporting System (DEERS) is a computerized data bank that lists all active and retired military members and their dependents if they meet the eligibility requirements. Active and retired military members are automatically listed but must take action to list their dependents and report any changes to family members' status (marriage, divorce, birth of a child, adoption, etc.) along with changes to mailing addresses. TRICARE contractors check DEERS before processing claims to make sure patients are eligible. You may contact DEERS at 1-800-538-9552.
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Durable Medical Equipment (DME) is purchased or rented medical equipment used for treatment of an injury or illness while medically necessary. DME may include wheelchairs, hospital beds, attachments, oxygen, respirators and medical supplies. DME purchases in excess of $500.00 or all rentals require preauthorization.
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A statement sent to a beneficiary and the provider showing that a claim was processed and indicating the amount paid to the provider. The EOB includes dates of service, who provided a particular service, the allowable charge and the billed amount as well as deductible, copay, cost-share and catastrophic cap information. If denied, an explanation of denial is provided.
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Fiscal Intermediaries (FI) are privately held companies contracted by the government to handle all TRICARE claims for any given region. The government directs FIs through federal regulations and guidelines. At times a Fiscal Intermediary may subcontract Claims Processors to adjudicate claims.
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A NAS statement is a certificate from the local military treatment facility (MTF) that states it can't provide the care that the patient needs. TRICARE Standard beneficiaries are required to obtain a NAS for inpatient mental health. With the exception of inpateint mental health care, the NAS requirement has been all but eliminated, except in limited circumstances when an MTF applies for a NAS waiver. MTFs may not apply for a NAS waiver for maternity, meaning the NAS requiremnet for maternity is removed completely.
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Any non-TRICARE health insurance that is not considered a supplement is considered OHI. This insurance is acquired through an employer, entitlement program, or other source. Under federal law, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, the Indian Health Service, or other programs or plans as identified by the TRICARE Management Activity.
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A Preferred Provider Organization is a network of healthcare providers who provide services to patients at discounted rates or cost shares.
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The Privacy Act of 1974 is a federal law that was established to provide a safeguard for individuals against invasion of personal privacy. The Federal Privacy Act imposes a legal responsibility on the Department of Defense and TRICARE Fiscal Intermediaries to assure that personal information about individuals collected by TRICARE is limited to that which is legally authorized and necessary.
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A doctor, hospital or other person or place that provides medical services and/or supplies.
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A referral is a request by the patient's Primary Care Manager (PCM) granting permission for the patient to seek specialty care outside of the PCM office.
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A defined geographic area served by a hospital, clinic, or dental clinic and delineated on the basis of such factors as population distribution, natural geographic boundaries, and transportation accessibility. For the Department of Defense (DoD) Components, those geographic areas are determined by the Assistant Secretary of Defense (Health Affairs) and are defined by a set of 5-digit ZIP codes, usually within an approximate 40-mile radius of military inpatient treatment facilities.
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Program administered by the Department of Defense (DoD) for the Department of Veterans Affairs that cost-shares for care delivered by civilian health providers to family members of totally disabled veterans that are eligible for retirement pay from a Uniformed Service of the United States.
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The MMSO helps ensure TRICARE members receive the health care services for which they are eligible. Located in Great Lakes, Ill., the MMSO serves as the centralized Tri-service point of contact, providing customer service, overseeing medical and dental care, and coordinating civilian health care services.
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A primary care manager is an MTF provider or network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. The PCM may be an individual doctor, a military provider, a military facility, a civilian clinic, an individual civilian provider, or Uniformed Services Family Health Plan (USFHP).
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A written confirmation that the requested PFPWD services or items are either not available from public facilities or are not adequate to meet the needs of the beneficiary’s qualifying condition. The PFPWD requires that public facilities be used first to the extent that they are available and adequate. The certification can be issued by the Commander of the MTF or an authorized administrator of the public facility. The certification is valid for 12 consecutive months from date of signature. A care-specific determination of public facility availability is conclusive and is not appealable.
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Situation where different members of the same family are enrolled with different TRICARE contractors. Each contractor maintains and tracks enrollment fees, copayments, and other TRICARE enrollee information for the family members enrolled in its own area.
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Ensures, with the support of the Surgeons General of the Military Departments, that Department of Defense (DoD) policy on health care is consistently, effectively and efficiently implemented throughout the Military Health System (MHS). The TMA is an activity of the Assistant Secretary of Defense (Health Affairs).
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Provides beneficiary enrollment, access to and referral for care, information on TRICARE options, information (including online access to the claims processing system for information about the status of a claim), assist beneficiaries with claim problems, and continuity of care services to all Military Health System beneficiaries. TSCs also fulfill the requirements of the Lead Agents (LAs).
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Medically necessary treatment that is required for illness or injury that would not result in further disability or death if not treated immediately, but treatment should not be put off. The illness or injury does require professional attention, and should be treated within 24 hours to avoid development of a situation in which further complications could result if treatment is not received.
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A non-participating provider is a TRICARE-certified hospital, institutional provider physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries but who has not signed a contract and does not agree to accept the TRICARE-allowable charge or file claims for TRICARE beneficiaries.
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A participating provider is a provider who has agreed to file claims for TRICARE beneficiaries, accept payment directly from TRICARE, and accept the TRICARE-allowable charge as payment in full for services rendered. Non-network providers may participate on a claim-by-claim basis. Providers may seek payment of applicable copayments, cost-shares, and deductibles from the beneficiary. After May 1, 2009, under the outpatient prospective payment systems (OPPS), all hospitals that are Medicare-participating providers must, by law, also participate in TRICARE for inpatient and outpatient care.
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TRICARE figures the allowable charge from all professional (non-institutional) providers' charges nationwide, with adjustments for specific localities, over the last year. The claims processor can verify the allowable amount for specific services per TRICARE guidelines. The allowable charge is also known as the TRICARE Maximum Allowable Charge (TMAC).
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Medical services that may be a result of a third party must first be reviewed for liability before TRICARE can consider payment. A Third Party Liability (TPL) form must be completed which explains whether or not another party may be responsible for making payment before TRICARE.
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TRICARE Prime is a managed care option offered in TRICARE Prime Service Areas (PSAs). TRICARE Prime enrollees receive most of their care from an assigned primary care manager (PCM) at a Military Treatment Facility, if available, or from the TRICARE network. The PCM provides and coordinates care, maintains patient medical records, and refers patients to specialists, if necessary. Specialty care referred by the PCM must be approved in advance by TriWest Healthcare Alliance Corp. Primary care is provided by the assigned PCM unless the PCM issues a referral.
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TRICARE Extra is available to all TRICARE eligible beneficiaries except ADSMs. Beneficiaries are responsible for fiscal year deductible and cost-shares. Beneficiaries may see any TRICARE-authorized provider they choose, and TRICARE will share the cost of covered services with the beneficiaries after deductible are met. TRICARE Extra is a preferred provider option. Beneficiaries choose a doctor, hospital, or other medical provider within the TRICARE provider network. By choosing a network provider, the beneficiary's out-of-pocket costs are reduced.
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TRICARE Standard is available to all TRICARE eligible beneficiaries except ADSMs. Beneficiaries are responsible for fiscal year deductible and cost-shares. Beneficiaries may see any TRICARE-authorized provider they choose, and TRICARE will share the cost of covered services with the beneficiaries after deductible are met. TRICARE Standard is a fee-for-service option.
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TRICARE For Life (TFL) is TRICARE's Medicare-wraparound coverage available worldwide to TRICARE beneficiaries regardless of age, provided they are entitled to premium-free Medicare Part A and also have Medicare Part B. TFL is available to all TRICARE/Medicare dual-eligible beneficiaries, including retired members of the National Guard and Reserve who are in receipt of retired pay, family members, widows/widowers, and certain former spouses. Dependent parents and parents-in-law are not eligible for TFL. TFL coverage is effective the same day that a beneficiary's Medicare Part B coverage becomes effective.
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The TRICARE form for Patient's Request for Medical Payment. This form is submitted by the beneficiary or sponsor requesting payment for services or supplies provided by civilian sources of medical care.
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Responsible for all civilian health care delivery to TRICARE beneficiaries outside the Military Treatment Facilities.
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All aspects of health services for the Department of Defense.
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Under the Federal Appropriations Act of 1993, you cannot be billed for the remainder or 'balance' of the provider charges after your civilian health insurance plan or TRICARE has paid their obligation. Federal law states that you are not legally responsible for amounts in excess of 15% above the TRICARE allowable charge even if the provider is not contracted and does not accept assignment of benefits.
